March 24, 2020Bracing for COVID-19: Flatten the Curve and Raise the Bar

An Interview with Fatima Al Sayah, PhD Public Health Researcher, University of Alberta, Canada

1. With the outbreak of the Coronavirus in Lebanon since February 21, 2020, how has Lebanon fared so far in comparison to other countries?

We should be very careful with cross-country comparisons, as they could be misleading. Countries vary in the number of cases per capita, cases growth rate, demographics of the general population (e.g., the percentage of elderly is important), health status of the population (such as the prevalence of chronic conditions), and testing capacity (the number of tests per capita) which all have an impact on the numbers we see emerge from different countries.
As of March 24, we have 304 confirmed cases of COVID-19 in Lebanon. In terms of numbers, Lebanon has 39 cases per 1 million of the population, which is still well below countries where the outbreak started around the same time but has been substantial (Italy: 1,057 cases/1 million; Spain 708 cases/1 million), yet higher than other countries in the Middle East (Jordan: 11 cases/1 million; Saudi Arabia: 16 cases/1 million). In terms of testing, reports suggest that we have completed around 6,000 tests so far, which amounts to around 800 tests/1 million—a number relatively acceptable compared to other countries.
It is also important to look at the growth of cases over time. Doubling time (which is to see how long it took for the number of confirmed cases to double) is being used as an indicator of the growth of cases. Currently, the average doubling time in Lebanon (after the 10th confirmed case) is 4.2 days. This estimate, however, changes on a daily basis, and for that it might be more useful to examine weekly averages. For instance, doubling time has increased from an average of 4.6 days between March 9 and 16, to 6.3 days between March 17 and 23.

Based on this, in my opinion, we have, so far, been able to delay the surge of cases, which bought us some time to get more prepared. The steepness of the surge will depend on the effectiveness of containment measures over the next few weeks.

2. What would be the tipping point where the situation could go out of control? Which population is most at risk of being affected?

It is difficult to specify a tipping point, especially in Lebanon where we lack comprehensive, systematic, and timely data collection that will help inform decision and policy making. At this stage of the outbreak, the situation could get out of control if a considerable number of people no longer adhere to containment measures. Reports suggest that younger asymptomatic individuals are responsible for over one third of transmissions, and this group needs to be attended to in terms of awareness campaigns.
There are sections of the population that are at higher risk in terms of severity of cases and worse outcomes, including the elderly, individuals with chronic conditions, and those who are immunocompromised. However, we should also pay attention to others who are at higher risk of getting infected, primarily healthcare professionals, as well as food service and transportation workers.

3. At what stage will Lebanon health system be overwhelmed?

This will depend on how the number of cases grows over the next few weeks. The Ministry of Public Health (MoPH) reported that we have around 11,800 general hospital beds and 2,300 intensive care beds available in public and private hospitals combined, with a reported occupancy rate around 75%. MoPH estimates that out of those who will catch COVID-19 in Lebanon, 600,000 will be symptomatic, and 90,000 of those will seek healthcare. Out of those 90,000, mild cases (72,000) will be managed through home isolation, 18,000 will require hospitalization, and 2,700 will require intensive care. Doubling time of cases over the last week in Lebanon has been around six days; if this continues, the 267 cases will become 534 in six days, 1,068 in another six days, 2,136 in another six, and so on. This will lead to a large surge of cases between the first and second weeks of May, overloading the available general and intensive care beds available in all hospitals. If containment measures are effective, the growth of cases should slow down, and the cases will spread over a longer period of time, thereby “flattening the curve”, without exceeding the healthcare system capacity. It is important to note that a healthcare system’s capacity also includes healthcare professionals, who are the key players here. Without doctors, nurses, and other specialists, we cannot operate any of our other resources.

4. What other measures must government take to contain the transmission of the virus?

Containment measures implemented in Lebanon to date align with the World Health Organization’s recommendations, and are similar to what has been implemented in other countries. At this stage of the outbreak, the government should increase testing capacity, and ensure that testing is available for free. We should keep in mind that confirmed cases are only a fraction of the actual cases, and increasing testing will help identify asymptomatic people who are contagious and risk infecting others. Testing is crucial for an appropriate response: The more testing we do, the more we know about the spread and extent of the outbreak, allowing us to make informed decisions at each stage.

5. Now that there is a lockdown till March 29, 2020, what should the government do next? What does it depend on?

First, based on recent data, the lockdown should be extended for another week. However, enforcement of a lockdown without socio-economic support is not sustainable. A large proportion of our society already lives under the poverty line—a situation exacerbated by the country’s recent economic turmoil. Governmental and non-governmental agencies as well as international organizations have been discussing different types of social and economic supports, but these have not been materialized sufficiently yet.

Second, we have been seeing over the last week a move from the government toward the decentralization of efforts and more engagement of local communities and municipalities. I think this is a very important step, but extensive coordination and support must be employed.

Third, we have been hearing a lot about “flattening the curve” but we should also think about “raising the bar”, which is to enhance the capacity of our healthcare system. Many hospitals have already been cancelling non-urgent and elective surgeries and procedures to increase the number of available beds, and the government has been trying to purchase more equipment including mechanical ventilators and protective gear. More efforts should be tailored toward training healthcare professionals, getting teams ready to deal with this outbreak, and providing all necessary support to these professionals.

Lastly, one of the key challenges this government faces is the lack of citizens’ trust, which is an outcome of several decades of corrupt governance and not just directed at the current cabinet. This is a time where every citizen has an immense responsibility toward oneself and others, and without the cooperation of the society as a whole, it will be extremely difficult for any government to appropriately contain and manage this outbreak. Transparency is extremely important now more than ever, along with comprehensive reporting of the outbreak status, experts and evidence based decision making, and engaging—rather than enforcing—the public in efforts to contain the outbreak.